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NHS Central London CCG

Improving the quality of life for people with neurological conditions

Neurology data profiles

Guidance for CCGs: our top tips for improving the efficiency of neurological services

Dr Nick Losseff, Clinical Director, Neuroscience SCN, NHS England, London Region Michael Oates, Quality Improvement Manager, Neuroscience SCN, NHS England, London Region Cerrie Baines, Project Manager, Neuroscience SCN, NHS England, London Region Ellen Keely, Analyst, NHS England, London Region March 2016 England.london-scn@nhs.net

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This guide This guide has been designed to help CCGs identify high impact areas for service improvement that will help improve the quality of life for people with neurological conditions and at the same time improve the efficiency and value for money of services. We have identified three key areas from an analysis of 2013/14 data available to NHS England, audits and reviews from neurological charities, national reviews and the work of the London Neuroscience Clinical Network. This guidance can support the development of sustainability and transformation plans, annual operation plans, specifications and other service development. There are over 255,000 people in London living with a neurological condition (excluding migraine (1.7 million more), dementia and stroke); that is double the number of people living with cancer, 30% more than the number of people with coronary heart disease or chronic kidney disease, 70% more than the number of people with cardiovascular disease1. Although neurological conditions account for 10% of all hospital admissions, 17% of all emergency admissions and 10% of consultations in primary care their profile has been low. Commissioning levers are still lacking and improving care will be down to local enthusiasm and good working partnerships. To facilitate this we have identified local neurology contacts so if you wish to discuss local neurological issues please contact the Network. There are already great examples of joint working in London:

Bromley: community neuro-rehabilitation team, community headache service

Camden: out of hospital care neurological services

Harrow: epilepsy pathway

Focus for activity and planning specialist.

Report: Focus for activity and planning, pages 3-5 CCG data, pages 6-8 Appendix 1 What neurology patients want, page 9 Appendix 2 Charity review of personalised care plans, page 10 Appendix 3 Charity review of Clinical nurse specialists, page 11 Appendix 4 Common conditions: estimated burden and cost saving, page 12 Appendix 5 Outpatient referral rates benchmarked all England, page 13 Appendix 6 Neurology metadata definitions, pages 14-17

1 London Neuroscience Strategic Clinical Network, Data profile: London and CCGs, 2014

Unplanned admissions: Sixty-three percent of the neurology budget is spent in secondary care of which half is unplanned. Many are for co-morbidities that could have been prevented. Use of outpatient appointments and access to neurological opinion: London has the highest rate of referral to outpatient appointments in England. Thirty percent of common neurological conditions referred to outpatients could have been managed in primary care. Potential saving for London £3 million. Non-specialised assessment and care of patients with neurological conditions in a secondary care setting: No hospital in London was identified where patients with a primary neurological diagnosis were systematically admitted under a neurology specialist . Impact on admission, length of stay, timely diagnosis, and appropriate treatment. Data profile for your CCG

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1. Unplanned admissions for people with chronic neurological conditions

Key fact Thirty three percent of the neurology programme budget is spent on unplanned secondary care. Fifty percent of this is attributable to multiple sclerosis (MS), Parkinson’s, migraine and epilepsy. Key data

Comment

Individuals living in the community with a neurological condition will at some point experience a deterioration of their condition that will require an emergency admission or acute management. Many will be for a co-morbidity that with better self-management or community support could have been prevented. The highest admission rates are for epilepsy, headache and Parkinsonism (See London: Comorbidities with highest incidence, page 8). In 2013/14 the number of non-elective (emergency) hospital admissions for people with MS in England was 23,665; costing the NHS over £43 million and (average £1,820 per admission). Non-elective care accounted for 46% of the overall spend on care for people with MS in hospital, whilst accounting for only 27% of the total admissions, and therefore represents a large opportunity to reduce cost. Urinary tract infections accounted for 14% of emergency MS admissions (compared with only 3% of the population admissions and cost an average £2,556 per admission). The total cost for all bladder and bowel related MS admissions in 2013/14 were more than £11m. Respiratory complications accounted for more than £5.5m of non-elective MS admission costs in 2013/14. 2

Potential solutions

Appendix 1 What neurology patients want, page 9 Appendix 2 Charity review of personalised care plans, page 10 Appendix 3 Charity review of Clinical nurse specialists, page 11

2 Measuring the burden of hospitalisation in multiple sclerosis: a cross sectional analysis of English Hospital Episode Statistics. 2009-2914, Multiple Sclerosis

Trust.

Emergency admissions per 100,000 population for all neurological conditions with or without co-morbidities e.g. urinary tract infection.

Central London 1,700 per 100,000 (all non -elective admissions (HES)/ all age CCG population (HSCIC) X 100,000)

England average2,363 per 100,000 (all non -elective admissions (HES)/ all age England population (HSCIC) X 100,000)

Primary non elective admissions per 100,000 population - where the primary diagnosis has been identified as a neurological condition.

Central London 304 per 100,000 (all non- elective primary diagnosis admissions (HES)/ all age CCG population (HSCIC) X 100,000)

London average 335 per 100,000

Tip 1. Identify all patients with a chronic neurologic condition in the population. Plans are agreed of how and when patients with such conditions are adopted into local existing integrated care models. These models should deliver risk stratification, prospective case management and strategies to manage unpredictable deterioration. These patients are at high risk of unplanned care

Tip 2. Review the major co-morbidities for neurological patients resulting in an A&E attendance or admission and commission improved support and treatment pathways

Tip 3. Strengthen community neurology services to provide effective self-management, needs led interventions (urgent and routine) and case management

Tip 4. Improve access to clinical nurse specialists and allied health professionals Tip 5. Improve access to local secondary care neurologic systems Tip 6. Implement personalised care plans

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2. Inefficient use of neurology outpatient appointments Key fact London has the highest referral rates for consultant neurology outpatient appointments in England. Key data Comment

High rates can clog up outpatient appointments for those needing timely specialist advice and pushing the burden onto non-specialised A&E assessment. The London Neuroscience Clinical Network’s common conditions workstream estimated that 30% of outpatient appointments for patients with headache, dizzy spells and faints could have been managed in primary care. See Appendix 4 for QIPP estimate of burden and savings, page 12. However, some neurological conditions can be difficult to diagnose and delays in accessing a neurological specialist, are widely cited in the literature as an area that needs improvement3. Potential solutions

Appendix 4 Common conditions: estimated burden and cost saving, page 12 Appendix 5 Outpatient referral rates benchmarked all England, page 13

Useful data source. See http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology for outpatient data benchmarking tool

3 National audit office report 2011

New outpatient neurology appointments for those aged 20+ DSR per 100,000 population (consultant)

Central London 1,684 per 100,000 England average 943.7 per 100,000

Tip 7. Promote educational campaign on common neurological conditions that can be managed in primary care and link video guides for common neurological conditions to your website/GP IT systems. See http://www.londonscn.nhs.uk/networks/mental-health-dementia-neuroscience/neuroscience/ for video guides.

Tip 8. Develop QIPP for referrals for common conditions. Consider GP practice/federation leads for common conditions e.g. GPwSI.

Develop pathways with local providers that enable access to expertise to triage patients with difficult symptoms or patients not responding to treatment. The approach should also support the management of common neurologic conditions within primary care.

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3. Non-specialised assessment and care of patients with neurological conditions in secondary care setting

Key fact “ … no hospital in London was identified where patients with a primary neurological diagnosis were systematically admitted under a neurology specialist”.4 Key Data Comment

Most patients with an acute neurologic illness are not primarily managed by neurological specialists but by general physicians, geriatricians, or ITU staff with or without advice through consultative visits or by telephone support from regional centres. The longstanding neurological service structure and peripatetic organisation of neurologists job plans explains the low numbers of neurologists particularly at acute general hospital level, and in addition this is compounded by unresponsive access to vital diagnostic tests e.g. MRI. Acute neurology pilots have taken place in London where neurologists have been working with A&E departments helping to reduce admissions and LOS, provide urgent treatment, and if people are admitted as an inpatient they are done so under neurology ownership. Other documentary evidence has identified higher levels of misdiagnosis and inappropriate treatment when a neurologist is not accessed early. Potential solutions

4. Conclusion and recommendation The London Neuroscience Clinical Network has identified three areas for focus for CCG attention that we believe would improve local neurological services. For this to happen we encourage dialogue between the CCG and their local neurology lead.

4 London Neuroscience Clinical Network secondary care audit 2014 and case for change for acute neurology, 2015.

Mean Length of Stay (LOS) in days (emergency admissions) Central London 4.0 days London 5 days

Tip 9. Emergency access is commissioned for patients with serious neurological conditions to facilities with appropriate expertise. This would require collaborative discussions with other commissioners and providers around regional models; such have been developed for stroke. CCGs / NHS England should seek expressions of interest for early adopters / evaluators of local secondary acute neurology services, in which patients assessed and admitted from emergency departments, are managed by appropriately trained neurology personnel from the outset of their care.

The London Neuroscience Clinical Network established a pilot to evaluate the benefits of Hyper Acute

Neurology Units in 2016. Early analysis shows a considerable benefit to early specialised opinion based on quality and efficiency of care.

Hyper acute neurology unit will provide 24/7 access to appropriate neurologic expertise and care. It will support patients attending through the A&E pathway or requiring an urgent intervention by ensuring they are managed at the outset by neurological specialists not general physicians, provide immediate specialist diagnostics, rapid management and discharge to appropriate services, and support other services through advice and telemedicine.

Tip 10. Get in touch with your local neurology lead through the Network. Contact: England.london-scn@nhs.net

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Central London data 2013/14

How well is your CCG performing against the London base rate?

This chart summarises Central London CCGs performance on a number of Neurology indicators compared to the London average. How much is your CCG spending compared to the London base rate?

-40%

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

Community and integratedcare (spend per 1000 pop)

Primary prescribing (spendper 1000 pop)

Non-elective admissions(spend per 1000 pop)

Elective admissions (spendper 1000 pop)

High cost and unbundledspending (spend per 1000

pop)

Outpatient attendances(spend per 1000 pop)

CCG spend on neurology services (PBR) NHS CENTRAL LONDON (WESTMINSTER) CCG

Distance from London Rate

Secondary care

Pe

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Table 1. Neurology indicators for Central London compared to the London average

TABLE 1Neurology indicatorsNHS CENTRAL LONDON (WESTMINSTER) CCG

Central London

(Westminster)

value

London

value

London

lowest

value

London

highest

value

Gap between

CCG and London

value

Gap between CCG

and London value

(%)

Prevelence of Epilepsy in 18+ (per 100,000 pop) 427 566 427 724 139- -25%

Proportion of those with Epilepsy % who are seizure free 61% 63% 50% 71% -2% -2%

Community and integrated care (£ spend per 1000 pop) 324 4,046 175 16,925 3,721- -92%

Primary prescribing (£ spend per 1000 pop) 8,718 8,044 5,724 11,891 674 8%

Non elective admissions (per 100,000 pop) 304 335 273 418 31- -9%

Non-elective admissions (£ spend per 1000 pop) 17,826 18,964 12,830 28,101 1,137- -6%

Waiting time for elective admissions (days) 38 48 30 69 10- -21%

Elective admissions (per 100,000 pop) 405 405 247 697 0- 0%

Elective admissions (£ spend per 1000 pop) 3,715 5,060 3,219 9,934 1,345- -27%

Epilepsy Non Elective Admissions (per 100,000 pop) 117 111 77 190 6 5%

Headaches and Migranes Non Elective Admissions (per 100,000 pop) 134 142 79 250 8- -6%

MS and Inflammatory Disorders Non Elective Admissions (per 100,000 pop) 6 6 - 15 0 1%

Parkinson's Non Elective Admissions (per 100,000 pop) 9 10 - 26 1- -9%

Proportion of inpatients who have a neurology consultant 35% 33% 22% 51% 2% 5%

Mean length of stay Non elective admissions (days) 4.0 5 2 13 1- -22%

Length of stay after an emergency admission for epilepsy (days) 1 2 1 3 1- -32%

Bed days (per 100,000 pop) 12,320 3,819 1,914 12,320 8,501 223%

Emergency epilepsy bed days (per 100,000 pop) 122 123 42 254 1- -1%

Emergency CNS infections bed days (per 100,000 pop) 35 70 28 128 35- -50%

High cost and unbundled spending (£ spend per 1000 pop) 1,064 1,622 44 5,329 558- -34%

Outpatient attendances (per 100,000 pop) 1,684 1,263 799 2,470 420 33%

Outpatient waiting times (weeks) 6.3 6.4 5 9 0- -2%

Range

HighestLowest

London AverageCCG Value

Bottom Quartile Top Quartile

Better than London base rateWorse than London base rateNeeds local interpretation

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London Co-morbidities Comorbidities with highest incidence:

Epilepsy – Caries limited to enamel, Convulsions, UTIs.

MS – UTIs, Unhibited neuropathic bladder.

Parkinson’s – Tetany, UTIs

Neuropathies – Cervical disc disorder with myelopathy

Cerebral Palsy – epilepsy, loose joint, convulsions

Headaches and migraines – Anaemia complicating pregnancy

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Appendix 1 What do people with neurological conditions want?

Neurological Alliance: patient survey, 2014

• Care that puts the person and their carers at the centre of the process and supports them to make informed decisions

• To self-manage and maintain independence • Early recognition, prompt and accurate diagnosis • Equal access to treatment and care, integrated and coordinated across all settings • Care closer to home and not in a medical environment • Specialist coordinator role to provide integrated care pathways (including out-of-hospital

services) • Clear local commissioning plans for neurology and allied services, drawing on better

understanding of neurology (including the role for the voluntary and community sector perhaps in needs assessment/planning and design)

• Stronger focus on preventative services and better use/understanding of, for example, community services, physical therapies, psychological support services

• Their views and experiences to be heard when planning care pathways • Specialist neurological understanding among GPs, commissioners and NHS staff • Easily accessible information about support networks and condition related issues for both

patients and professionals (many professionals don’t know what help is available to offer to patients)

• Community and vocational support to be provided • End of life care plan; “to die with dignity” • Risk stratification tools to identify those at risk • Support for carers and families.

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Appendix 2 Charity review of personalised care plans Sources 1. The invisible patients – revealing the state of neurology services, 2015, Neurological Alliance. 2. Epilepsy in England - the local picture, 2014, Epilepsy Action.

There is growing evidence that approaches to person-centred care such as shared decision making and self-management support can improve a range of factors including patient experience, care quality and health outcomes (Health Foundation, 2014:11). Research has demonstrated that when people play a more collaborative role in managing their health and care they are less likely to use emergency hospital services (De Silva, 2011) and are more likely to stick to their treatment plans (De Silva, 2012) and take their medicine correctly (National Institute of Health and Care Excellence, 2009). Effective care planning and coordination is an essential aspect of care for people living with a long term health condition. The National Service Framework for Long-Term Conditions recommended that ‘people with long-term neurological conditions are offered integrated assessment and planning of their health and social care needs’ (Department of Health, 2005:4). • 71.5% (4,603) of respondents have not been offered a care plan to help manage their condition. (1) • Only 14% (128/947) of people with epilepsy report have a written care plan. (2)

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Appendix 3 Charity review of Clinical nurse specialists Sources 2. Epilepsy in England - the local picture, 2014, Epilepsy Action. 3. Evidence for multiple sclerosis specialist service: findings for GEMSS evaluation project, 2015

(Generating Evidence in Multiple Sclerosis Services) 4. Parkinson’s nurses – affordable, local, accessible and expert care. A guide for commissioners in

England, 2011.

Most specialist neurological nurses are disease specific. They can improve the quality of care and lower its cost, mainly by reducing unnecessary admissions and reducing consultant neurologist outpatient demand, thus freeing capacity for complex cases. • MS specialist nurses (MSSN) are the professionals that the most people with Multiple Sclerosis

(MS) (78%) have seen about their MS in the past year. 51% of people with MS reported that they had seen a neurologist in the past year about their MS. However, 10% said they had seen neither, and hence had not had the specialist annual review recommended by NICE.(3)

• Using conservative assumptions, the Generating Evidence in Multiple Sclerosis Services (GEMSS) data suggests that each WTE MSSN participating in GEMSS has saved £77.4k in ambulatory care costs (GP appointments, neurology appointments and A&E visits) during the year. Whilst reductions in emergency admissions are difficult to measure, we can be confident that MSSNs reduce admissions and that the savings generated are likely to far exceed the costs of employing them. (3)

• Parkinson’s nurses are essential to deliver expert, accessible care for people with Parkinson’s at all stages of life. On average a nurse can save each year:

• £43,812 in avoided consultant appointments, £80,000 in unplanned admissions to hospital, £147,021 in days spent in hospital. (4)

• Only half (52%, 475/905) of people with epilepsy told us that they have seen an epilepsy specialist nurse. (2)

• Access to specialists also plays a key role – those with access to an MSSN or neurologist are more than twice as likely to be taking a disease modified drug. (2)

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Appendix 4 Common conditions: estimated burden and cost saving

Headache Dizzy spells TLoC

How common. 20,000 per 100,000 population

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4,900 per 100,000 population

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Syncope: 930 per 100,000 GP attendances (note total incidence is 1810: 100,000 - many patients do not go to their GP)

Epilepsy: 562 per 100,000 population

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Total number of first outpatient appointments

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80,708

Percent estimate of patients attending outpatients with the symptom

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30percent 15percent 15percent

Percent estimated waste of those attending8

30percent 30percent 25percent

Cost of outpatient10

£219

Cost saving of proportion of patients not needing neurology outpatient services

£1,590,755 £795,377 £662,815

Total saving £3,048,947 Potential saving of £95,000 per CCG

5 London Strategic Clinical Network, London Neurology Profile, November 2014. Based on British Association for the Study of

Headache estimate. Available from: http://www.londonscn.nhs.uk/publication/london-neurology-profiles-by-ccg/ 6 Neuhauser, HK (2007) Epidemiology of Vertigo, Current Opinion in Neurology, 20(1):40-6. Based on 1-year prevalence

estimates for vertigo. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17215687, 7 London Strategic Clinical Network, London Neurology Profile, November 2014. Based on numbers of people on GP lists in

London registered with epilepsy. Available from: http://www.londonscn.nhs.uk/publication/london-neurology-profiles-by-ccg/ 8 http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data

9 Perception of neurologists on their out-patient clinics (Straw poll of neurologists involved in Network projects)

10 Payment by Results 2014/15 Tariff for first attendance single/multi professional neurology outpatient appointment.

Potential savings:

Current data on outpatients is not broken down by condition and not all patients with a common neurological symptom will be seen in a neurological clinic, for example some may be seen in an ENT clinic. The outpatient figure used also does not include nurse led appointments. However, from the data available and the experience of the Network’s neurologists we have estimated the following financial saving.

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Appendix 5 Outpatient referral rates benchmarked all England

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Appendix 6 Neurology metadata definitions

Indicator Definition Data source

Definition of numerator

Definition of denominator

Methodology Caveats

Epilepsy pathway indicators

Prevalence of epilepsy

The number of people aged 18 years and over receiving drug treatment for epilepsy recorded on practice registers as a proportion of all people (18+) registered in the CCG.

Health & Social Care Information Centre (HSCIC).

The number of people aged 18 years and over receiving drug treatment for epilepsy recorded on practice register.

18+ years CCG registered population

Number on register for 2013-14 divided by 18+ population registered in CCG

QOF statistics are generally considered to be complete and robust. However, there may be a question regarding the quality of external cause coding.

Percentage of patients with epilepsy on drug treatment and seizure free

Proportion of individuals aged 18 years and over receiving drug treatment for epilepsy recorded on practice register who have been seizure free in the last 12-months

Health & Social Care Information Centre (HSCIC).

The number of people aged 18 years and over receiving drug treatment for epilepsy recorded on practice register seizure free in the last 12-months

The number of people aged 18 years and over receiving drug treatment for epilepsy recorded on practice register including exceptions.

Divide the number seizure free by the total number on the CCG register.

QOF statistics are generally considered to be complete and robust. However, there may be a question regarding the quality of external cause coding.

Length of stay after an emergency admission for epilepsy.

Average length of stay (calculated as a mean number of days) after an emergency admission for epilepsy.

Hospital Episode Statistics (HES)

Sum of total length of stay for emergency epilepsy admissions

Total number of emergency epilepsy admissions

Sum of length of stay after emergency epilepsy admission divided by total emergency epilepsy admissions.

HES inpatient data is generally considered to be complete and robust. However, there may be a question regarding the quality of external cause coding. Some of these cases may represent admissions for observation due to observed symptoms following an external cause event. There may be differences in admission thresholds. There may be variation between Trusts in the way hospital admissions are coded. There may be variation in data recording completeness.

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Neurological Indicators

Non Elective admissions (per 100,000 pop)

The number of non- elective admissions to hospital with a primary diagnosis of a specific neurological condition, expressed as a crude rate per 100,000 (CCG responsible population)

Inpatient Hospital Episode Statistics (HES)

Count of non- elective admissions for specific neurological conditions; primary diagnosis; CCG responsible population

All age CCG registered population

Non elective admission data divided by CCG registered population, result multiplied by 100,000 for rate

HES inpatient data is generally considered to be complete and robust. However, there may be a question regarding the

quality of external cause coding. Some of these cases may represent admissions for observation due to observed symptoms following an external cause event. There

may be differences in admission thresholds. There may be variation between Trusts in the way hospital

admissions are coded. There may be variation in data recording completeness.

Waiting time for elective admissions (days)

The average number of wait days for those electively admitted to hospital for a Neurological condition

Inpatient Hospital Episode Statistics (HES)

Total sum of wait days for elective admissions

Total number of elective admissions

The total sum of wait days for those electively admitted to hospital divided by the total number of elective admissions

Elective admissions (per 100,000 pop)

The number of elective admissions to hospital with a primary diagnosis of a specific neurological condition, expressed as a crude rate per 100,000 (CCG responsible population)

Inpatient Hospital Episode Statistics (HES)

Count of elective admissions for specific neurological conditions; primary diagnosis; CCG responsible population

All age CCG registered population

Elective admission data divided by CCG registered population, result multiplied by 100,000 for rate

Proportion of patients admitted with a primary neurology diagnosis that are managed by a consultant neurologist

In-patient admissions where the specialist code was recorded as consultant neurologist. The main specialty code for Neurology is 400.

Inpatient Hospital Episode Statistics (HES)

Percentage of Finished Admission Episodes with primary diagnosis for specified neurological conditions managed by consultant neurologist. Specialist code was recorded as consultant neurologist (400).

Number of finished admitted episodes for a primary diagnosis of specified neurological condition by CCG of residence.

Total primary Neurology admissions managed by a Neurologist consultant divided by the total Primary Neurology admissions.

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Total bed days Total number of bed days for all primary neurological admissions per 100,000 population

Inpatient Hospital Episode Statistics (HES)

Total sum of episode duration for both non elective and elective admissions

All age CCG registered population

Total sum of episode duration divided by total population, result multiplied by 100,000 for rate

HES inpatient data is generally considered to be complete and robust. However, there may be a question regarding the

quality of external cause coding. Some of these cases may represent admissions for observation due to observed symptoms following an external cause event. There

may be differences in admission thresholds. There may be variation between Trusts in the way hospital

admissions are coded. There may be variation in data recording completeness.

Emergency Epilepsy bed days

The sum of individual hospital lengths of stay following an emergency admission where the primary diagnosis was for Epilepsy per 100,000 population

Inpatient Hospital Episode Statistics (HES)

Sum of individual hospital length of stay following an emergency admission where the primary diagnosis was for Epilepsy.

Number of patients registered at a GP practice - April 2014.

Emergency Epilepsy bed days divided by CCG registered population, result multiplied by 100,000 for rate

Emergency CNS infection bed days

The sum of individual hospital lengths of stay following an emergency admission where the primary diagnosis was for CNS conditions per 100,000 population

Inpatient Hospital Episode Statistics (HES)

Sum of individual hospital length of stay following an emergency admission where the primary diagnosis was for a CNS infection.

Number of patients registered at a GP practice - April 2014.

Emergency CNS infection bed days divided by CCG registered population, result multiplied by 100,000 for rate

DSR of admissions (Primary Diagnosis) (Epilepsy, Headaches and Migraines, MS, Parkinson’s)

Age standardised rate of emergency admissions to hospital due to specific condition with a primary diagnosis, for those aged 20+ (CCG resident population).

Hospital Episode Statistics

Count of emergency admissions for each condition using specific diagnosis codes; 20+ years by CCG resident population.

20+ years CCG resident population

Admission data obtained from HES Inpatient data by ICD10 codes described in: http://www.yhpho.org.uk//resource/view.aspx?RID=207314 and standardised by CCG resident population against European Standard Population 2013. Rate per 100,000.

HES inpatient data and ONS population statistics are generally considered to be

complete and robust. However, there may be a question regarding the quality of external cause coding. Some of these cases may represent admissions for

observation due to observed symptoms following an external cause event. There

may be differences in admission thresholds. There may be variation between Trusts in the way hospital

admissions are coded. There may be variation in data recording completeness.

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Mean length of stay

Average length of stay (days) when admitted to hospital with a primary diagnosis of a neurological condition

Inpatient Hospital Episode Statistics (HES)

Sum length of stay (days) for episodes with a primary diagnosis for a neurological condition.

Count of completed inpatient episodes with a primary diagnosis of a neurological condition.

Total length (days) of completed spells divided by the number of spells.

Budget indicators

Payment by Results Neurology Programme Budget (2013-14)

Spend of the neurology programme budget for each care setting per 100,000 weighted population

2013/14 Programme Budgeting Benchmarking Tool

Expenditure data are taken from the 2013-14 CCG programme budgeting returns. Programme budgeting returns represent a subset of overall NHS expenditure data.

All age CCG registered population

Calculated by dividing the expenditure on own population by the selected CCGs population and multiplying by 1000 to allow benchmarking with other CCGs.

Payment by Results tariffs do not include non-mandatory prices and some activity is excluded from PbR and remains subject to local prices. Primary prescribing: Primary care activity relating to prescribing or pharmaceutical services, excluding those which relate to prevention/health promotion. Outpatient: Outpatient attendances or procedures. High cost/ Unbundled: Expenditure on adult, neonatal and paediatric critical care (allocated via the primary diagnosis of the normal inpatient admission). Expenditure on high cost/unbundled drugs and devices, and other. Community and Integrated care: Care delivered outside of a hospital and within local communities. Activity carried out within community hospitals should be classified as secondary care activity.